Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Élaboration d’un modèle théorique pour étudier le rapport au savoir en didactique de l’histoire et en éducation à la citoyenneté

Ce mémoire a pour objet d’étude la notion du rapport aux savoirs historiques des élèves de l’ordre secondaire. Plus précisément, il sera question des relations existant entre la conception qu’entretiennent les élèves de l’histoire et du métier de l’historien, leur conception de l’action humaine dans l’histoire et leur sentiment d’être eux-mêmes, aujourd’hui, des acteurs politiques effectifs. Ce sujet est ancré dans le contexte de l’introduction des prescriptions en matière d’éducation à la citoyenneté dans le programme d’histoire de niveau secondaire. Cet ajout a pour conséquence d’introduire de nouveaux objectifs en matière d’éducation à la citoyenneté : l’élève, par l’étude de l’évolution démocratique, doit être amené à comprendre le rôle de l’action humaine dans l’histoire, lui faisant ainsi comprendre la valeur de sa propre participation à la vie sociale et politique. Cela étant dit, les recherches montrent que les enseignants et les enseignantes tardent à adopter la terminologie propre aux compétences du programme de formation en histoire et éducation à la citoyenneté et perpétuent un enseignement de l’histoire-récit qui fait la part belle aux grands évènements et aux grands hommes (Bouhon, 2009; Moisan, 2011). De plus, les manuels utilisés laissent peu de place aux individus ou aux groupes d’individus agissants et présentent rarement leurs actions de manière à rendre compte de leur efficacité (Éthier, 2001; Lefrançois, Éthier et Demers, 2011). Enfin, les recherches montrent que les élèves sont enclins à expliquer les changements à l’aide d’une histoire personnalisante, occupée principalement par les grands hommes et les hauts faits de l’histoire politique et militaire (Hallden, 1986 ; Carretero, Jacott, Limon, Lopez-Manjon et Leon, 1994 ; Carretero, Asuncion et Jacott, 1997 ; Tutiaux-Guillon et Fourmond, 1998). En explorant les conséquences complexes de ces différents constats, nous avons ressenti une insatisfaction à l’égard de la capacité d’explication de ce phénomène qu’offrait le champ conceptuel de didactique de l’histoire. Par conséquent, ce mémoire portera sur le transfert de la notion de rapport au savoir au domaine de la didactique de l’histoire à partir de la sociologie et de l’anthropologie. Le modèle théorique proposé a été obtenu grâce à une recherche spéculative qui a été inspirée des méthodes de Martineau, Simard et Gauthier (2001) et de Van der Maren (1996).

INTRACELLULAR OSMOREGULATION IN THE ESTUARINE MOLLUSC VILLORITA CYPRINOIDES VAR. COCHINENSIS (Mollusca: Bivalvia) Hanley

The present investigation is dedicated to understanding various mechanisms of salinity tolerance in the estuarine clam V. cyprinoides var. cochinensis. Even though V. cyprinoids var. cochinensis and V. cyprinoides are found to coexist in the same area, V. cyprinoids is reported to tolerate higher salinities than variety cochinenesis. Variations in the salinity of sea water may affect the aquatic organisms through specific gravity control and variations in osmotic pressure. The specific gravity of most soft tissues is close to that of normal seawater. Many bottom living forms, both attached and motile, have very high specific gravities eg.villorita cyprinoids. Villorita spp. Occurs abundantly in the reaches of the estuary and backwaters of Kerala. In both marine and estuarine forms, it is observed that mantle employs a lesser quantity of amino acids compared to adductor and foot. The regulation of cell volume is not carried out equally in all types of tissues. The capability of salinity tolerance is an aggregate of both the capabilities of extra cellular anisosmotic and intracellular isosmotic regulations in osmoconforming animals. The ultimate aim of water regulation is to regulate the cell volume.T here are slight changes occur in cell volume even in osmoregulators. These studies can also help in revealing the changes brought about in the cellular organelles like lysosomes, which were found to have a role in the osmoregulatory process. The osmoregulatory machinery of estuarine animals is more streamlined for a successful life in the estuarine regime.

Designing in the real world is complex anyway - so what?

Designing is a heterogeneous, fuzzily defined, floating field of various activities and chunks of ideas and knowledge. Available theories about the foundations of designing as presented in "the basic PARADOX" (Jonas and Meyer-Veden 2004) have evoked the impression of Babylonian confusion. We located the reasons for this "mess" in the "non-fit", which is the problematic relation of theories and subject field. There seems to be a comparable interface problem in theory-building as in designing itself. "Complexity" sounds promising, but turns out to be a problematic and not really helpful concept. I will argue for a more precise application of systemic and evolutionary concepts instead, which - in my view - are able to model the underlying generative structures and processes that produce the visible phenomenon of complexity. It does not make sense to introduce a new fashionable meta-concept and to hope for a panacea before having clarified the more basic and still equally problematic older meta-concepts. This paper will take one step away from "theories of what" towards practice and doing and try to have a closer look at existing process models or "theories of how" to design instead. Doing this from a systemic perspective leads to an evolutionary view of the process, which finally allows to specify more clearly the "knowledge gaps" inherent in the design process. This aspect has to be taken into account as constitutive of any attempt at theory-building in design, which can be characterized as a "practice of not-knowing". I conclude, that comprehensive "unified" theories, or methods, or process models run aground on the identified knowledge gaps, which allow neither reliable models of the present, nor reliable projections into the future. Consolation may be found in performing a shift from the effort of adaptation towards strategies of exaptation, which means the development of stocks of alternatives for coping with unpredictable situations in the future.

Optimization in the Technological Steps for the Fabrication of Large Area Micromirror Arrays

Micromirror arrays are a very strong candidate for future energy saving applications. Within this work, the fabrication process for these micromirror arrays has been optimized and some steps for the large area fabrication of micromirror modules were performed. At first the surface roughness of the insulation layer of silicon dioxide (SiO2) was investigated. This SiO2 thin layer was deposited on three different type of substrates i.e. silicon, glass and Polyethylene Naphthalate (PEN) substrates. The deposition techniques which has been used are Plasma Enhanced Chemical Vapor Deposition (PECVD), Physical Vapor Deposition (PVD) and Ion Beam Sputter Deposition (IBSD). The thickness of the SiO2 thin layer was kept constant at 150nm for each deposition process. The surface roughness was measured by Stylus Profilometry and Atomic Force Microscopy (AFM). It was found that the layer which was deposited by IBSD has got the minimum surface roughness value and the layer which was deposited by PECVD process has the highest surface roughness value. During the same investigation, the substrate temperature of PECVD was varied from 80° C to 300° C with the step size of 40° C and it was found that the surface roughness keeps on increasing as the substrate holder temperature increases in the PECVD process. A new insulation layer system was proposed to minimize the dielectric breakdown effect in insulation layer for micromirror arrays. The conventional bilayer system was replaced by five layer system but the total thickness of insulation layer remains the same. It was found that during the actuation of micromirror arrays structure, the dielectric breakdown effect was reduced considerably as compared to the bilayer system. In the second step the fabrication process of the micromirror arrays was successfully adapted and transferred from glass substrates to the flexible PEN substrates by optimizing the conventional process recipe. In the last section, a large module of micromirror arrays was fabricated by electrically interconnecting four 10cm×10cm micromirror modules on a glass pane having dimensions of 21cm×21cm.

Variability in the Stability and Productivity of Transfected Genes in Chinese Hamster Ovary (CHO) cells

In the field of biologics production, productivity and stability of the transfected gene of interest are two very important attributes that dictate if a production process is viable. To further understand and improve these two traits, we would need to further our understanding of the factors affecting them. These would include integration site of the gene, gene copy number, cell phenotypic variation and cell environment. As these factors play different parts in the development process, they lead to variable productivity and stability of the transfected gene between clones, the well-known phenomenon of “clonal variation”. A study of this phenomenon and how the various factors contribute to it will thus shed light on strategies to improve productivity and stability in the production cell line. Of the four factors, the site of gene integration appears to be one of the most important. Hence, it is proposed that work is done on studying how different integration sites affect the productivity and stability of transfected genes in the development process. For the study to be more industrially relevant, it is proposed that the Chinese Hamster Ovary dhfr-deficient cell line, CHO-DG44, is used as the model system.

Financial protection in the UK building industry: a guide for clients and the construction supply chain.

There is a clear need for financial protection in the construction industry, both to guarantee satisfactory completion of construction projects and to guard against non-payment. However, the cost of financial protection is often felt to be disproportionately high, with unnecessary overlap between different measures. The Reading Construction Forum has commissioned and steered research which is published in this report in an effort to bring the problem out into the open and to clarify the various options open to the various parties and stakeholders in the construction process. "Financial Protection in the UK Building Industry" is the first definitive report on the subject, offering an accurate and simple guide that all levels within the construction industry can understand. This accessible new guide considers the problem of financial protection and clearly lays out the alternative solutions.It looks by turn at the client, the main contractor, and the sub-contractor, discussing which financial protection options are available to each of them, and considers the pros and cons of each option. The cost of each type of financial protection is weighed against the amount of protection provided and the risks involved. The book concludes with guidance for consultants, emphasising relevant points to consider when advising clients and contractors about which type of financial protection to choose. "Financial Protection in the UK Building Industry" was researched by a literature search, collection of statistical data, and financial data, as well as discussions with clients, contractors, sub-contractors and consultants. This investigation has shown that the direct costs of implementing financial protection measures are marginal, and that wider adoption of payment protection would create a more equitable situation between contracting parties.This guide will enable anyone in the construction industry to consider all the options, and determine what is the best solution for them. "Reading Construction Forum Financial Protection for the UK Building Industry" was complied by the University of Reading, funded by the Reading Construction Forum. The Forum has recently commissioned and steered a number of high-profile reports covering important aspects of the construction industry. Members of the Forum include major companies which are concerned with achieving high quality in the design, construction and use of commercial, retail and industrial buildings. All are committed to change and innovation in the British and European construction industries.

The impact of market and supply configurations on the costs of tendering in the construction industry

The cost of tendering in the construction industry is widely suspected to be excessive, but there is little robust empirical evidence to demonstrate this. It also seems that innovative working practices may reduce the costs of undertaking construction projects and the consequent improvement in relationships should increase overall value for money. The aim of this proposed research project is to develop mechanisms for measuring the true costs of tendering based upon extensive in-house data collection undertaken in a range of different construction firms. The output from this research will enable all participants in the construction process to make better decisions about how to select members of the team and identify the price and scope of their obligations.

Influences on secured lending property valuations in the UK

A significant part of bank lending in the UK is secured on commercial property and valuations play an important part in this process. They are an integral part of risk management within the banking sector. It is therefore important that valuations are independent and objective and are used properly to ensure that secured lending is soundly based from the perspective of both lender and borrower. The purpose of this research is to examine objectivity and transparency in the valuation process for bank lending and to identify any influences which may undermine the process. A detailed analysis of 31 valuation negligence cases has been followed by two focus groups of lenders and valuers and also questionnaire surveys of commercial lenders and valuers. Many stakeholders exist, for example lenders, borrowers and brokers, who are able to influence the process in various ways. The strongest evidence of overt influence in the process comes from the method of valuer selection with borrowers and brokers seen to be heavily involved. There is some also some evidence of influence during the draft valuation process. A significant minority of valuers feel that inappropriate pressure is applied by borrowers and brokers yet there is no apparent part of the process that leads to this. The panel system employed by lenders is found to be a significant part of the system and merits further examination. The pressure felt by valuers needs more investigation along with the question of if and how the process could dispel such feelings. This is seen as particularly important in the context of bank regulation.

Provider diversity in the English NHS: a study of recent developments in four local health economies

Objectives: The overall objective of the research was to assess the impact of provider diversity on quality and innovation in the English NHS. The aims were to map the extent of diverse provider activity, identify the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organisations within the NHS, and the factors that affect the entry and growth of new private and TSOs. Methods: Case studies of four Local Health Economies (LHEs). Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and Third Sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results: Involvement of diverse providers in the NHS is limited. Commissioners’ local strategies influence degrees of diversity. Barriers to the entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS Trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions: There is scope to increase the participation of diverse providers in the NHS, but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Policy ‘framing’ and evidence-based planning: ‘epistemic communities’ in the multi-jurisdictional environment of an enlarged Europe

The following paper builds on ongoing discussions over the spatial and territorial turns in planning, as it relates to the dynamics of evidence-based planning and knowledge production in the policy process. It brings this knowledge perspective to the organizational and institutional dynamics of transformational challenges implicit in the recent enlargement of the EU. Thus it explores the development of new spatial ideas and planning approaches, and their potential to shape or ‘frame’ spatial policy through the formulation of new institutional arrangements and the de-institutionalization of others. That is, how knowledge is created, contested, mobilized and controlled across governance architectures or territorial knowledge channels. In so doing, the paper elaborates and discusses a theoretical framework through which the interplay of knowledge and policymaking can be conceptualized and analyzed.

Influences on secured lending property valuations in the UK

A significant part of bank lending in the UK is secured on commercial property and valuations play an important part in this process. They are an integral part of risk management within the banking sector. It is therefore important that valuations are independent and objective and are used properly to ensure that secured lending is soundly based from the perspective of both lender and borrower. The purpose of this research is to examine objectivity and transparency in the valuation process for bank lending and to identify any influences which may undermine the process. A detailed analysis of 31 valuation negligence cases has been followed by two focus groups of lenders and valuers and also questionnaire surveys of commercial lenders and valuers. Many stakeholders exist, for example lenders, borrowers and brokers, who are able to influence the process in various ways. The strongest evidence of overt influence in the process comes from the method of valuer selection with borrowers and brokers seen to be heavily involved. There is some also some evidence of influence during the draft valuation process. A significant minority of valuers feel that inappropriate pressure is applied by borrowers and brokers yet there is no apparent part of the process that leads to this. The panel system employed by lenders is found to be a significant part of the system and merits further examination. The pressure felt by valuers needs more investigation along with the question of if and how the process could dispel such feelings. This is seen as particularly important in the context of bank regulation.

Commercial property loan valuations in the UK : the changing landscape of practice and liability

This paper is the first of two which aim to examine the major legal liability implications of changes to the commercial property loan valuation process caused by the recession in the UK property market and to make recommendations to valuers and their professional institutions to improve the quality of the process and the result. This paper identifies the market background to commercial property lending and discusses the implications of the falls in value for lenders and valuers. These include two major strands; first, the outcome of discussions between the representative bodies of these two groups and, second, the increasing litigation caused by lenders suing valuers for professional negligence. The discussions between representative groups have driven a debate on the valuation process leading to a number of reports and guidance notes. This paper discusses the outcomes paying particular attention to the basis of valuation for loan purposes and the provision of additional information in valuation reports. This paper also reviews the legal framework which influences the relationship between the lenders and valuers and discusses the duty of care. The role of instructions in the valuation process, the significance of the identity of the person to be advised and the possibility of a conflict of interest arising are all considered. The paper also addresses the issue of the standards required of a commercial loan valuer, including how this is interpreted by the courts and the legal status of professional guidance notes. The paper concludes by identifying potential areas for dispute within the loan valuation process and raising a number of research questions concerning the operation of this process which are addressed in a following paper.

Lessons from real estate partnerships in the UK: Drivers, barriers and critical success factors

Purpose – This paper seeks to summarise the main research findings from a detailed, qualitative set of structured interviews and case studies of Real Estate Partnership (REP) schemes in the UK, which involve the construction of built facilities. The research, which was funded by the Foundation for the Built Environment, examines the evolution of REPs in the UK and in Europe. The paper also aims to analyse best practice, critical factors for success, and lessons for the future. Design/methodology/approach – The research in this paper is based around ten semi-structured interviews conducted with senior representatives from corporate occupiers, property consultants, legal practices and REP service providers. Findings – The research in the paper demonstrates that REPs are particularly suited to the UK, where lease lengths are relatively long, and the level of corporate real estate owner-occupation is often higher than elsewhere. It also shows that further research is needed to examine the future shape and form of the UK REP market. Research limitations/implications – The paper is based on a limited number of in-depth case study interviews. The paper shows that further research is needed to find better ways to examine REPs empirically. Practical implications – The paper is important in highlighting a number of main issues in developing REPs: identifying with occupier's objectives; risk transfer and size of contract; and developing appropriate innovation and skills. Originality/value – The paper examines the drivers, barriers and critical success factors (at strategic and operational levels) for REPs in the UK in detail and will be of value to property managers, facilities managers, investors, financiers, and others involved in the REP process.

Lessons from the private finance initiative in the UK: benefits, problems and critical success factors

Purpose – This paper summarises the main research findings from a detailed, qualitative set of structured interviews and case studies of private finance initiative (PFI) schemes in the UK, which involve the construction of built facilities. The research, which was funded by the Foundation for the Built Environment, examines the emergence of PFI in the UK. Benefits and problems in the PFI process are investigated. Best practice, the key critical factors for success, and lessons for the future are also analysed. Design/methodology/approach – The research is based around 11 semi-structured interviews conducted with stakeholders in key PFI projects in the UK. Findings – The research demonstrates that value for money and risk transfer are key success criteria. High procurement and transaction costs are a feature of PFI projects, and the large-scale nature of PFI projects frequently acts as barrier to entry. Research limitations/implications – The research is based on a limited number of in-depth case study interviews. The paper also shows that further research is needed to find better ways to measure these concepts empirically. Practical implications – The paper is important in highlighting four main areas of practical improvement in the PFI process: value for money assessment; establishing end-user needs; developing competitive markets and developing appropriate skills in the public sector. Originality/value – The paper examines the drivers, barriers and critical success factors for PFI in the UK for the first time in detail and will be of value to property investors, financiers, and others involved in the PFI process.